The costs and benefits of scaling up interventions to prevent poor birth outcomes in low-income and middle-income countries: a modelling study

Summary Background We estimated the benefits and costs of a set of preventive interventions that could be delivered during antenatal care to prevent poor birth outcomes, including small-for-gestational-age and preterm births. We built on the assumptions and analyses underlying the Lancet Series on small vulnerable newborns (SVNs) and extended that work by incorporating more recent data, focusing only on the subset of preventive interventions, and examining a broader range of effects. A primary aim of the study was to provide a framework that decision makers could use to design programmes for women and children. Methods The analyses used the Lives Saved Tool (LiST) to estimate the effects and costs of scaling up the 11 preventive interventions identified in the SVN Series to improve birth outcomes. We used LiST estimates of effects and costs to estimate benefit–cost ratios (BCRs) for two intervention packages (one with interventions proven to improve birth outcomes and one with proven interventions plus interventions with potential to improve birth outcomes) and for the individual interventions in these packages for 80 low-income and middle-income countries (LMICs). Findings Both packages of interventions had BCRs more than 1, with a proven package BCR of 7·3 (IQR 5·3–9·1) and a proven plus potential package BCR of 5·8 (4·4–6·9). We found that in all cases the individual interventions had BCRs more than 1, there was a wide range of BCR values for the different interventions, and the BCR varied depending on package and country. Interpretation The analyses presented in this Article provide evidence that there are preventive interventions that, if scaled up in LMICs, could have a large effect on child health and provide benefits that greatly exceed the costs. Funding Global Affairs Canada.


Details on costing assumption
As described in the main body of the article, service delivery costs are estimated based on volume of clients and include cost categories for drugs and consumables, labor, and the costs of inpatient days and outpatient visits.Costs for drugs and consumables were supplied by the UNICEF supply catalogue 1 and MSH International Drug Price Indicator Guide 2 .Costs for staff salaries prepopulated with assumptions for salaries, benefits, and time utilization were drawn from WHO CHOICE.Costs for inpatient days and outpatient visits were also drawn from WHO CHOICE estimates 3 .See Supplemental Table 1 for detailed intervention-specific costing inputs.
Target populations and those in need of services are estimated based on demographic projections, LiST estimates for incidence and etiology, and literature on incidence and prevalence of various conditions.The cost per case is estimated using an ingredients approach which incorporates quantities and cost of drugs and supplies, provider time, and numbers of inpatient and outpatient visits from the One Health Tool databases developed with WHO 4 .RMNCAH-N program costs such as supervision, training, monitoring and evaluation are calculated as an additional percentage of intervention costs.Default program cost categories and percentages (Supplemental Table 2.) have been provided, based on SUN nutrition plan costing exercises, the EPIC immunization studies, and National AIDS Spending Assessments 5 .Users are encouraged to adapt these cost categories and the assumed level of costs based on recent country-specific data if available.Users have the option of configuring the program costs categories and entering costs either as a percentage of direct costs, or as an absolute number.
Health system costs are captured based on a structure that disaggregates supply chain costs, wastage costs, infrastructure investments, and other health system costs such as governance and health information systems.The estimation of costs for logistics was applied as a mark-up rate to the value of commodity, including dugs and supplies, costs in order to approximate resource requirements for expanding the supply chain.We used the average percentage of commodity value needed for expanding the supply chain in a number of countries with varied baseline logistics system condition 6 .Wastage costs were estimated to be 5% of commodity costs to reflect that certain quantity of drugs were not used past the expiration date.
Infrastructure investment assumes that the facility network will need to expand to meet expanding numbers of services required to scale up a given plan 6 .The investment required is estimated based on the change between each year's number of services and the associated number and costs of inpatient days and outpatient visits and includes facility construction, medical equipment, and furniture costs required to expand the network in order to realistically roll out the service package being analyzed.No infrastructure investment is needed for the analysis because all the interventions in the packages were assumed to be add-ons of the existing antenatal care visits.
Other health system costs such as governance and health information systems are estimated based on country income level and applied to intervention-specific costs.A ratio of other health system costs to intervention-specific costs was derived from previous WHO work 6 that includes a disaggregated analysis of costs by country for service delivery in RMNCH.This has been adapted for LiST Costing to allow estimation of other health system costs for a given package of care or an individual intervention.

Stop smoking education
Midwives 100 Counseling provided during ANC visits 10 4

Outpatient visits
No outpatient visits for the interventions included in the analysis.All interventions are assumed to be provided as add-ons to existing ANC visits.